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WELL—PERMIT APPLICATION F...,iM S17E <br /> J MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> JAN 3 0 2002 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> EfJb'I ,)f�rlCrfd, :- .�lh (209) 458-3449 <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work descnbed• This application is made in=mpliance Aith San <br /> Joaquin County Development Title,Chapter 9-1115,3 and.the Standards of San Joaquin County Public Health Services,Envirenmen aii Health Division. <br /> wEs Location essalS <br /> Stre City Parcel# /� <br /> s Address Z a —City,S� zlp��heneit `7 3-7 <br /> PROPERTY Owner �� A � L�`�- <br /> Ad Address X37 s1,u�, ,dl pity �t H " t - . � - <br /> 27Phone#. <br /> C-57 Contractor - <br /> Consultant!Sub Contractor <br /> Address City Lit# Phone# <br /> ,Township Range Section <br /> GIS Coordinates:X Y <br /> K TO BE PERFORMED' []DES i RLJCTlON(choose type glow) <br /> NEW WELL/BORING(CPT,GECPROBE,HYDROPUNCH,HAND-AUGER,OTHEi3) OVER-SORT✓ <br /> kCIL BORING# ^L , J PRESSURE CiZCUT <br /> LL# <br /> Grout 5� Y <br /> 'Other. �fications: <br /> COMMENTS: <br /> TYPE OF VVELL INSTALLATION TYPE CONSTRUGnON SPECIFICATIONS <br /> MONITORING I]HOLLOW STEM DIA-OF BOREHOLE MULTIPLE CASILVGS? YES NO WELL CASING DIA <br /> 7 C OTHER: <br /> EXTRACTION ❑AIR HAMMEr'Z/DRIVEN CASING THICKNES�4Z,'-- �E OF d2lN - D STEL [1 <br /> [j VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL �r1�L��TR�AIE TYPE TO BE USED: []AUGERS I]HOSE <br /> AIR SPARGE USH POINT GROUT SEAL PUMPED: I]Yes XNo (NOTE: FRE FALL DEPTH 1S 30') <br /> _k60IL BORING I]HAND AUGER GROUT SPECIFICATIONS: � T BOLTED TRAF=iC BOX or Q STOVE FIFE <br /> ©OTHER: P ER APPROX BORING DEPTH , r 1 D <br /> CONDUCTOR CASING PROPOSED? s (if YES list specifications here)_ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin - <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> J J <br /> Signed x <br /> G Title/Company <br /> / C � . <br /> Date Al <br /> Print Name � B tl �' <br /> DEPARTMENT USE ONLYlq65 _5 <br /> ` <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area <br /> Application Accepted <br /> By HY Date <br /> Grout Inspection ate <br /> Final Inspection ay <br /> Destruction inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: ;AID# <br /> PE CODES FEE INFONT REMITTED CHECK# REC'D BY DATE PEIZMrr 1 SERVICE REQUEST# IDiVOICE <br /> 5 p <br /> 45 1�1 -7 Z aZ cc Olto� � �� <br /> 9/27100 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit-Encroachment clot <br /> . <br />